Robbyn E Sockolow, MD Associate Professor of Clinical Pediatrics Director of Pediatric Gastroenterology New York Presbyterian- Weill Cornell Medical Center Taking Care of the Whole Child

HEALTH SUPERVISION: OUTLINE Growth and nutrition Disease activity Prevention and surveillance Psychosocial well being

HEALTH SUPERVISION: OUTLINE Growth and nutrition Height, Weight, BMI, Bone Health Disease activity Mission = Remission Prevention and surveillance Vaccinations Cancer screening Psychosocial well being Screening for anxiety/depression

AREAS OF SUPERVISION Vaccination Status Vitamin Status Bone Health Ophthalmologic health Dermatologic health Annual PPD

VACCINES

IMMUNOSUPPRESSION: Treatment with glucocorticoids (prednisone 20 mg/d equivalent, or 2 mg/kg/d if less than 10 kg, for 2 weeks or more, and within 3 months of stopping). Treatment with effective doses of 6- mercaptopurine/azathioprine (effect on safety not established) and within 3 months of stopping. Treatment with methotrexate (effect on safety not established) and within 3 months of stopping. Treatment with infliximab/adalimumab (effect on safety not established) and within 3 months of stopping. Significant protein-calorie malnutrition. SANDS ET AL INFLAMM BOWEL DIS 2004;10:677

VACCINES THAT ARE KILLED AND CONSIDERED SAFE IM/SC influenza vaccine Hepatitis A and B vaccine Meningococcal vaccine Human Papilloma virus vaccine Pneumovax

Anthrax vaccine Intranasal influenza Measles-mumps-rubella (MMR) Polio live oral vaccine (OPV) Rotavirus (oral) Smallpox vaccine Tuberculosis BCG vaccine Typhoid live oral vaccine Varicella Yellow fever LIVE VACCINES

Proportion of subjects achieving a post-vaccination of Pneumococcal Polysaccharide Vaccine geometric mean titer (GMT) 1 μ g / 100 Melmed G et al. Am J Gastroenterol 2010; 105:148–154

PEDIATRIC IBD: HEALTH SCREENING Confirm vaccine efficacy at diagnosis Maximizes time available to immunize Titers for Varicella, Hepatitis BsAb and Hepatitis A IgG, MMR?? PPD at diagnosis Confirm before biologics

VACCINES IN PEDIATRIC IBD: CONTINUE INACTIVATED VACCINATIONS Inactivated vaccines—stay on schedule Tetanus, Diphtheria, Pertussis (DPT) Human Papilloma virus (HPV) Influenza (injectable only) Pneumococcal Hepatitis A and Hepatitis B Meningococcal Melmed GY. Inflamm Bowel Dis 2009;15:1410–1416. Wasan SK et al., Clin Gastroenterol Hepatol 2010;8:1013–1016

LIMIT LIVE/ATTENUATED VACCINATIONS NO live or attenuated vaccines if taking IM/Biologics Measles mumps rubella (MMR) – wait 6 weeks Varicella (titer at diagnosis) – wait 4-12 weeks Intranasal influenza Oral polio Smallpox Yellow Fever Melmed GY. Inflamm Bowel Dis 2009;15:1410–1416. Wasan SK et al., Clin Gastroenterol Hepatol 2010;8:1013–1016

TRAVEL RELATED LIVE/ATTENUATED VACCINES Anthrax Bacillus Calmette Guérin (BCG) Smallpox Oral Typhoid Yellow Fever

PEDIATRIC IBD: LIMITS ON LIVE/ATTENUATED VACCINATIONS Consider immunization before initiation of immunosuppressive therapy Consider checking post-vaccine titers Melmed GY. Inflamm Bowel Dis 2009;15:1410–1416. Wasan SK et al., Clin Gastroenterol Hepatol 2010;8:1013–1016

BONE HEALTH

PEDIATRIC IBD: BONES AT RISK At risk for decreased bone mass Often present at diagnosis (disease related) Can be acquired over time (treatment related) Potential for increase in fracture risk Vertebral and long bone Pappa H, et al. J Pediatr Gastroenterol Nutr 2011;53:11–25 Sylvester FA, et al. Inflamm Bowel Dis 2007;13:42-50

Vitamin D 3 & Crohn’s Disease: Manitoba IBD Registry Increased prevalence of vitamin D deficiency in Inflammatory bowel disease Leslie WD, Miller N, Rogala L, Bernstein CN. Vitamin D status and bone density in recently diagnosed inflammatory bowel disease: the Manitoba IBD Cohort Study. AJG Jun;103(6)

NORMAL BONE VS OSTEOPOROTIC BONE Loss of trabecular plates results in weakened bone structure significantly increasing risk of fractures. 75 yo normal woman47 yo s/p multiple vertebral compression fractures

DEXA SCREENING FOR BONE HEALTH: PEDIATRIC PEARLS Order total body (minus skull) Need a pediatric experienced site! Age and sex adjusted Z scores (not T-scores!) Patient size affects the test—may have to adjust Interpretation Z-score < ‐ 2.0 = significant deficit Z-score < -1.0 = monitor closely Pappa H, et al. J Pediatr Gastroenterol Nutr 2011;53:11–25 Lewiecki EM, et al. Bone 2008;43:

Fewtrell et al, Bone densitometry in children assessed by dual x ray absorptiometry: uses and pitfalls Arch Dis Child 2003: 88;

PEDIATRIC IBD:WHEN TO OBTAIN DEXA Recommended at diagnosis Repeat “when clinically indicated” Slowed growth velocity (height z-score <2) Previous BMD z-score < -1 Delayed puberty or amenorrhea Severe course especially if low albumin Prolonged steroid use (> 6 months) Pappa H, et al. J Pediatr Gastroenterol Nutr 2011;53:11–25

BONE IN PEDIATRIC IBD: THERAPY Control inflammation Optimize nutrition Monitor growth and development (menses) Weight-bearing activity Optimize Vitamin D/calcium status Specialist if complication occurs e.g. Compression fracture Pappa H, et al. J Pediatr Gastroenterol Nutr 2011;53:11–25

VITAMIN D IN PEDIATRIC IBD Deficiency in >30% of pediatric IBD patients Higher risk: Darker complexion, active disease Measure yearly 25-OH level: Later winter/spring Keep level > 32 ng/mL 800 to 1,000 IU/day as maintenance (D 3 ) Supplement Calcium 1,000—1,600mg a day Pappa H, et al. Pediatrics 2006;118: Pappa H, et al. J Pediatr Gastroenterol Nutr 2011;53:11–25

CANCER PREVENTION

PEDIATRIC IBD: CANCER SCREENING Skin cancer 1 o prevention (hats, sunglasses, SPF > 30) Yearly dermatologic screening Especially if using immunomodulators/Biologics Articles for both Thiopurines and Biologics in Rheum literature Peyrin-Biroulet et al Gastro 2011 Cesame Group Nancy France Long MD, et al. Inflamm Bowel Dis 2011;17: Rubenstein et al. Am J Gastroenterol 2009;104: Kramagar et al J Dermat Treat UCSF 2012

PEDIATRIC IBD: CANCER SCREENING Colonoscopy Screen 7-10 yrs if colonic disease diagnosed Yearly if diagnosed with PSC Surveillance every 1-2 subsequent years Pouchoscopy and cuff biopsies after IPAA

MENTAL HEALTH

ASSESSING PSYCHOSOCIAL WELLNESS Situational distress vs prolonged functional impairment 25% develop anxiety and/or depression Frequent follow up visits allow screening Adherence and psychosocial wellness Focus on the child/ adolescent Mackner LM, et al. Inflamm Bowel Dis 2006;12: Engstrom I. J Child Psychol Psychiatry 1992;33: Szigethy E, et al. J Pediatr Gastroenterol Nutr 2004;39:

INTERVENTION:DEPRESSION/ANXIETY Appropriate referral to a mental health professional Cognitive behavioral therapy (CBT): best evidence for treating anxiety, depression Szigethy E, et al. Child Adolesc Psychiatr Clin N Am 2010;19:

PSYCHOSOCIAL INTERVENTION: PEDIATRIC IBD Therapeutic relationship Support groups, CCFA camp ? Role of self-management programs ?Role of social networks/websites Shepanski MA, et al. Inflamm Bowel Dis 2005;11:164–170 Szigethy E, et al. Inflamm Bowel Dis 2009;15: